Case Study

UST HealthIQ automations helped insurance provider streamline APCD reporting

This insurance company struggled with data issues to submit institutional and dental claims files to state-regulated All-Payer Claims Databases (APCD). After deploying UST HealthIQ, we helped the company automate the end-to-end data workflow to securely ingest, transform and submit claims files per EDI 837 regulations, saving countless hours of manual work.
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OUR CLIENT

Founded nearly a decade ago, this insurance provider offers healthcare and Medicare Advantage plans to individuals, families and small groups. The company also offers technology solutions to providers and payers to streamline the delivery of insurance services to patients. With a customer-centric, technology-driven approach, the company generates more than $5 billion in revenue annually.

THE CHALLENGE

Automating EDI 837 data feeds for All-Payer Claims Database compliance

The company had a 6-week window to automate electronic data interchange (EDI) submissions for institutional and dental insurance claims to avoid penalties and remain compliant with All-Payer Claims Database (APCD) regulations. These state-run databases collect eligibility, provider and claims files from private and public payers. The insurance provider’s IT team needed a solution to seamlessly encrypt and decrypt claims and ingest, transform and map the data feeds to APCDs according to EDI 837 state guidelines.

THE TRANSFORMATION

Deploying a HIPAA-compliant data transformation for EDI 837 claims files

We deployed the EDI module of UST HealthIQ, a configurable, managed SaaS solution for healthcare claims. The seamless solution, developed with custom parsers and automated workflows, ingests protected health information (PHI) claims data files from provider SFTP servers, converts the data to the EDI 837 format, and transmits the information back into the company’s data repository. From there, the insurance company submits the fully compliant claims files to state APCD systems—without manual intervention. To ensure healthcare data security, the claims files are automatically encrypted during the ingestion and transformation processes and tokenized at-rest.

Now that the company has an automated, HIPAA-compliant data encryption solution for its 837 claims information, employees can focus on servicing customers rather than correcting errors and resubmitting data files.

THE IMPACT

Achieving EDI compliance for healthcare claims

The company successfully met its tight compliance deadline and avoided financial penalties, saving thousands of dollars. The automated solution also saved employees countless hours of manual data manipulation. Productivity increased because employees no longer had to resubmit rejected claims files.

RESOURCES

https://www.ust.com/en/industries/healthcare/interoperability/compliance-modernization

https://www.ust.com/en/cms-compliance-workshop

https://www.ust.com/en/industries/healthcare-and-life-sciences